CEAUSSIC: Anthropology, Public Health and National Security

“The AAA’s Ad Hoc Commission on Anthropology’s Engagement with the Security and Intelligence Communities (CEAUSSIC) continues its work. Our main activities at present include: 1. the writing of a report to the AAA on the widely and hotly debated Human Terrain System of the U.S. Army (by the fall), 2. The editing of a casebook illustrating the diversity of kinds of practicing anthropology, including associated ethical questions, with a primary emphasis upon the security sector broadly conceived, 3. And providing support for the AAA’s ongoing ethics process. In an effort to keep our work transparent and part of the public and disciplinary discussion of all of the above, CEAUSSIC is also going to be contributing a monthly entry to the AAA’s blog. Each entry, by different CEAUSSIC members, will address topics that have arisen or that we have been thinking about, which we will continue to discuss via the blog, a discussion in which we hope you will also participate.”

Anthropology, Public Health and National Security—An Eyewitness Account of Colliding Worlds

Monica Schoch-Spana, CEAUSSIC Member and Senior Associate of the Center for Biosecurity of the University of Pittsburgh Medical Center

August 21, 2009

This blog entry builds upon the earlier submissions by my CEAUSSIC colleagues, Rob Albro and Laurie Rush (and a paper I presented at the 2008 AAA annual meeting). Rob, Laurie, and the ad hoc commission as a whole, have called upon our discipline to learn more about the diverse forms of engagement that U.S. anthropologists currently have with the security sector and to broaden the debate about the ethical implications of such work. To that end, I present my own experiences as an anthropologist employed in a university-based, health security “think tank”—the Center for Biosecurity of the University of Pittsburgh Medical Center (www.upmc-biosecurity.org). Prior to that, my colleagues and I were with the Johns Hopkins University Center for Civilian Biodefense Strategies. Our founding mission in 1998 was to inform policy decisions and promote practices that help prevent the development and use of biological weapons, and should prevention fail, lessen the death and suffering that would result. We populate the analyst world aptly described by Rob in his June 2009 commentary.

Some biographical details are worth noting. My biodefense “career” has had 3 overlapping episodes: an ethnographer who was curious about the conditions giving rise to national security concerns about biological weapons and thinking ahead to new research avenues after my having studied the nuclear weapons complex in the 1990s; an anthropologist who became concerned about the dangers of biological weapons as well as the decrepit state of the public health infrastructure and who was willing to join an interdisciplinary team to work on these policy issues; and lastly, a “public health preparedness” professional and U.S. citizen increasingly worried about the repressive domestic and foreign policies unfolding in response to the perceived threat of WMD terrorism and the 9/11 attacks. Throughout this time, I have felt as an anthropological insider-outsider – both in the thick of things, helping shape preparedness policy and practice, and at the sidelines, reflecting on the direction of the field and the country.

As detailed below, much of my work over the past decade has been to question officials’ erroneous visions of people’s behavior in large-scale emergencies and to advocate for a more nuanced and comprehensive role for the public in mitigating health disasters. “How will the public react to a biological attack” is a fundamental question underpinning U.S. policy and practice in the realm of terrorism preparedness and response. This same question undergirds recent government approaches to other extreme health events that involve novel, life-threatening infectious diseases such as SARS or pandemic influenza. From the viewpoint of national security and public health officials, the danger that these emergent “threats” present includes how a population deals with the hazard in their midst. Through my research, writing, and policy advising I have sought to challenge the uncritical, commonsense notions with which U.S. authorities at all levels of government have broached the question of what is called “the public’s response.”

Each of the notional publics within dominant biodefense discourse – panicky mob, anxious audience, self-reliant stockpiler, resilient survivor – warrants critical examination not simply because they may reflect poor reasoning, but because they represent different political possibilities harnessed to the preparedness project. The specific interventions I recount below (and others not noted) have been part of a personal and professional journey to articulate forms of government that can effectively and humanely tackle the social problem of extreme health events, including intentional epidemics. Among well-established and newly emerging security circles, as in the case of biodefense, a constant struggle exists to move policies in certain directions and to assert a particular meaning (and associated means) of collective security over others.

PANICKY MOB

A notion of the public in early circulation among biodefense professionals, and still deeply entrenched in the minds of some, is that of the panic-stricken crowd: consumed with fear, the public becomes selfish and brutish, trampling the needs of others and foiling the efforts of professional responder to manage the emergency. Playing one-dimensional roles in hypothetical bioterrorism scenarios and tabletop exercises, members of the public tend to surface as mass casualties or as hysteria-driven mobs that self-evacuate affected areas or resort to violence to gain access to scarce, life-saving drugs (Schoch-Spana 2003).

Contrary to the scary stories authorities tell each other, panic is the exception and creative coping is the norm during extreme events, according to extensive social research into disasters, terrorist attacks, and even novel disease outbreaks. Communicating this extant body of knowledge artfully to policymakers has been a key intervention in overturning the prevalent image of the panicky mob.

In 2001, a sociology colleague and I, for instance, prepared an article for preparedness professionals that criticized the tendency within bioterrorism policy and response planning to assume the public to be “irrational, uncoordinated, and uncooperative in emergencies—not to mention prone to panic” and that outlined officials’ obligations to foster circumstances in which people can readily cope with extreme health events (Glass & Schoch-Spana 2001:217).

To upend the prevailing image of a hysterical public during biological attacks, we wrote of the public’s temperate response during the anthrax letter crisis. What was described in news reports as rampant panic-buying of gas masks and antibiotics was a behavior in which few people actually engaged, according to academic polls. Moreover, mass testing and antibiotic distribution at affected work sites was an orderly process, as hundreds and even thousands of people waited in line for their turn.

ANXIOUS AUDIENCE

The complex realities of the 9/11 attacks and anthrax mail crisis refined, however, many authorities’ understanding of the public not simply as a problem to be managed, but a constituency to be served: anxious people understandably in need of good information about the danger and what to do about it. Prevailing approaches among preparedness officials toward the public have shifted in great measure from an earlier emphasis on containing social disorder to communicating emergency health information to citizens. I call this notional public the “anxious audience.”

Subsequent to the anthrax letter attacks, colleagues and I embarked upon several projects to inspire preparedness professionals to think more critically about their understanding of the public in strictly mass-mediated, informational terms. A key project was the Working Group on ‘Governance Dilemmas’ in Bioterrorism Response which we convened in 2003-04. This was an advisory body comprised of decision-makers from all levels of government; seasoned public health practitioners; experts in disaster sociology and psychology, infectious diseases, and risk communication; and community organizers and advocates for special populations.

The Working Group encouraged authorities to place current commitments to improving public communication within a broader understanding of the governance dilemmas that commonly arise during epidemics. Among our products was a leadership guide distributedto top decision-makers nationwide including mayors, governors, and health authorities that outlined strategies to avert the socially disruptive qualities of large-scale outbreaks — http://www.upmc-biosecurity.org/website/resources/leadership/index.html .

Breaking down the simplistic, lingering image of the public panicked under conditions of scarce medical resources was one concrete goal of this advisory panel. The group’s final report instructed officials in the facts that “[n]ot everyone experiences the same material security or faith in the health care system, nor do they feel equally entitled to make demands on authorities” (Schoch-Spana et al. 2004:34). There must be material evidence that access is based on need, not money or favored status.

Such proof includes contingency plans that make free emergency treatment or prophylaxis available and that locate clinics in accessible locations for people without transportation. To ensure that the disenfranchised understand their interests will be protected in an emergency, authorities should interact with them in non-crisis periods, ideally through programs that address self-identified health priorities. When tragic choices do arise concerning life-saving resources, such decisions demand full disclosure and every effort made to distribute benefits and burdens justly.

SELF-RELIANT STOCKPILER

Another notional public emerging in the aftermath of the fall of 2001 was the self-reliant stockpiler – an individual prepared to take care of himself by putting together an emergency “kit” and becoming versed in unconventional threats and self-protective actions. Emergency kits and self-study of threat agents, at first glance, are sensible activities: Gathering a flashlight, radio, fresh batteries, non-perishable foods, maintenance medications, and other “basics” is a do-able, human-scaled project that—depending upon the circumstances—can have real material value.

At another level, defining citizen preparedness in terms of stockpiling manifests profound deficits and misguided priorities. It is predicated on an ethos of individual responsibility, rather than mutual aid. It can also divert public attention from the larger institutional and political context in which society incurs certain risks, including domestic policies that undergird the fragile state of U.S. public health and medical care delivery systems. It certainly helps for private citizens to be informed and alert to specific symptoms in a fast-moving epidemic, but even if people know better, they may put off seeing a physician if they have no health insurance and are behind on the rent or the utility bill.

An intervention to overcome the atomizing and depoliticizing effects of preparedness campaigns was the Working Group on Community Engagement in Health Emergency Planning, which I convened in 2006 (Schoch-Spana et al 2007). This advisory panel argued that the civic infrastructure—rather than the lone citizen or undifferentiated masses—ought to be a key agent in setting a community’s emergency policies. By “civic infrastructure,” the working group meant the dynamic whole comprised of the public’s collective wisdom and ability to solve problems; voluntary associations that arise from shared interests or a public good, and that meet on-line or face-to-face; and social service organizations that look out for the well-being of various groups.

Before a disaster happens, the civic infrastructure can raise awareness, energize trust in authorities, help decide fair and feasible contingency plans, and delineate shared responsibilities to protect against mass tragedy. During the crisis, civic networks can relay self-protective advice, reach out to people who do not use mainstream media or who do not trust public officials, provide information about what is really happening on the ground, and give material and moral support to first responders and health professionals. Following an emergency, the civic infrastructure can help recovery by providing comfort and reassurance in ways that government cannot, and by recommending improvements to public policies that guard against extreme events and that shape future response and restoration.

CONCLUSION: RESILIENT SURVIVOR

For the purpose of this discussion, I want to make explicit the reasoning behind specific efforts to unmask the public archetypes in U.S. preparedness policy. In taking on the panicked public ideal, colleagues and I have tried to undermine biodefense discourse that legitimates the use of force against U.S. residents and the trampling of their freedoms in the name of security against the dual threats of terrorism and disease outbreaks.

Supportive of the shift toward risk communication, I still find it necessary to pick apart the anxious audience model. Unequal access to health care or suspicion toward officials based in prior events, more so than communication “breakdowns,” present formidable barriers to the public’s ability to engage in protective behaviors or act on reasonable requests from health professionals.

I have also tried to define citizen preparedness in a way that overcomes the atomizing and depoliticizing effects of mainstream security discourse about self-reliance and stockpiles. The more important work of citizens, in my view, is not putting together a “go kit” but monitoring and intervening in the political processes that affect the vitality of public health and safety institutions, or working toward improved zoning and building codes in the case of earthquake and hurricane safety.

Have these interventions made a difference?

The most influential impact has taken repeated interventions over the last decade as well as the success of the community engagement working group. Released in October of 2007, “Homeland Security Presidential Directive 21: National Strategy for Public Health and Medical Preparedness” (HSPD-21) identified community resilience as one of the “four most critical components of public health and medical preparedness,” alongside biosurveillance, countermeasure distribution, and mass casualty care. The spirit of the directive, as well as feedback from biodefense colleagues indicate that some of my writings had registered at high levels of government.

HSPD-21 has ushered in the latest notional public, that of the resilient survivor:

“Where local civic leaders, citizens, and families are educated regarding threats and are empowered to mitigate their own risk, where they are practiced in responding to events, where they have social networks to fall back upon, and where they have familiarity with local public health and medical systems, there will be community resilience that will significantly attenuate the requirement for additional assistance.” – HSPD-21

Reframing the public from a panic-stricken mob to a band of hearty survivors is a positive development and more realistic in terms of the empirical record. But like the other notional publics it displaces, the resilient survivor ideal has its faults. So, I am ambivalent about how my work has shaped this piece of preparedness doctrine. If people and communities more-or-less rebound from large-scale tragedy, the thinking could go, perhaps officials need not concern themselves with actively cultivating supportive mechanisms, investing in public health and safety institutions, or repairing decaying physical infrastructure. Moreover, a policy focus on generalized resilience could obscure the vulnerabilities of specific individuals and groups of people, and even hold disaster victims responsible for their own tragedy, for not having demonstrated some ideal “innate” ability to bounce back (Schoch-Spana 2008).

The contributions to biosecurity that I outline above do not fit neatly with the terms of anthropology’s present ethical debates, driven largely in relation to Department of Defense developments such as the Human Terrain System, the Minerva Initiative, and a new counter-insurgency doctrine mindful of local culture (as Rob has discussed). Nor does my work, I believe, easily align with the boundaries to current controversy within public health about the militarizing effects of a counter-bioterrorist agenda and a preparedness mindset. I hope that colleagues in both public health and anthropology come to see security not simply as a homogenous, static sector with “obvious” ethical pitfalls, but more as something in the making, worth wresting the meaning and means of.

References

Glass T, Schoch-Spana M. Bioterrorism and the public: how to vaccinate a city against panic. Clinical Infectious Diseases 2002; 34:217-223.

Schoch-Spana M, O’Toole T, Inglesby T et al, for the Working Group on ‘Governance Dilemmas’ in Bioterrorism Response. Leading during bioattacks and epidemics with the public’s trust and help. Biosecurity & Bioterrorism 2004; 2(1):25-40.